Transcript

I’m just back from an ISSWSH meeting, which I highly recommend that you guys do if you haven’t been yet. Here’s their website for the Fall course. Maybe once every year or two I recommend. You can see the content is pretty amazing. These are the handouts that they had. I thought I would just run through some of the highlights of the lecture that Andrew Goldstein gave on dyspareunia.

Dyspareunia

Dyspareunia, as you guys know, to a gynecologist, it’s like saying back pain to a orthopedic surgeon or an internist—the etiologies are so numerous that it’s almost the name of a symptom not a diagnosis. Although there was an article, an editorial, in the Green Journal Obstetrics and Gynecology about three years ago now where the editor said, “We’re not treating it as well as we can, and often times it really does go undiagnosed.” But even with that being the case, it’s worth looking at in more detail, the different diagnoses/etiologies

I’m going to unmute your mic, Kathleen, because I know you’ve been to this meeting (ISSWSH). You are going to have things to say about it. It would be very helpful to talk about it, I think. I don’t know if you’re able to talk. Can you hear me, Kathleen?

Kathleen Posey: Yeah, I can hear you. Can you hear me?

Charles Runels: Yep. We’re recording this because even though not so many compared to speaking, not a huge percentage of our people make it to the call, usually it’s in the neighborhood of 20 or 30 people out of over 1,000 people, I think it’s really worth thinking about pain/dyspareunia.

The good news is that often times when we have pain and it’s not easily diagnosed, our O-Shot® procedure seems to be working. Whether it’s healing damaged tissue or if it’s causing a decrease in inflammation like it does with lichen, I don’t know. But I thought we’d run through these known causes. I don’t pretend to be giving this presentation the way Andrew Goldstein gives it, but I’ll hit the headlights, the highlights. Hopefully, you guys can hear the lecture for yourself sometime in the next year or so.

This is the textbook that he helped edit about dyspareunia, which I highly recommend that you go through this. Eventually, I think there will be a chapter about an O-Shot. You can find this on Amazon.

This is the one, the version that he wrote for patients.

These are the known causes [see video]. Talk about this for a second, Kathleen. What on here do you see us helping with? Obviously, we wouldn’t try to treat fibroids with an O-Shot, but talk about this list for a second, and just the diagnosis of dyspareunia in general. Can you see it?

Kathleen Posey: Yeah, I can see it. I basically put PRP wherever the pain is. I map it out. I rule out the things like yeast infections, chlamydia, endometriosis, PID. I treat them just like we would treat those, but usually when there’s no reason, I just get out that Q-tip or just my index finger and say, “Where’s the pain? Does it hurt here?” Then I put the PRP.

Actually, a case I talked about a couple weeks ago was a anal cancer in a 40 year old that had radiation and complained of menopause and decreased lubrication. She went to a plastic surgeon who did Thermi-va on her, which only made her small vagina smaller. But mainly the pain was a posterior fourchette. I did put the PRP and did an O-Shot® because I do both. About two to three weeks later, her pain got better. That’s my method.

You can look at all these diagnoses. We know how to treat most of these things, but it’s the unknown ideology of the pain that I think the PRP helps. It doesn’t always. I had a classic vulvodynia around Hart’s line that was real painful, and she really didn’t respond that well, but that’s just one out of the many that I’ve treated. I’ll still try it on another patient like that, too. I wouldn’t limit it to that.

Charles Runels: Beautiful. Let me add to what you just said.

First of all, I agree. Most of the people, by the time they get to us for an O-Shot®, the patient’s already, before they are willing to pay cash, they’ve already been to other physicians and had lots of tests done. The good is that most of these things, if they were there, have already been treated.

The other thing I would add, which I know you do this, Kathleen. I know you treat some people for free, as do I, and that we’re both careful not to keep money if people don’t get well. I highly, highly recommend that everyone do that. If you’re treating pain and someone doesn’t get well and you keep their money, they feel like we stole from them. Even though we’re not used to giving back copays or whatever, insurance doesn’t refund money if we don’t … Obviously, we know we can’t get everyone well, highly recommend that if you treat someone for pain, and they don’t get well, either repeat it or refund their money.

By the way, the reason I’m talking to Dr. Posey for those of you that don’t know, you’ve been involved with the group right now for quite a few years. She’s been teaching it to other gynecologists. She’s a gynecologist, board certified, out of the New Orleans area, who has recently presented some research where she treated lichen sclerosis with a combination of surgical procedures and PRP, and teaches that method. A lot of experience seeing many thousands of women over the years as gynecologist and very well-trained, busy surgeon in the day. Back in the day, I know you were a high … Anyway, lots of experience.

Back to this list. Back to the list. The endometriosis, obviously, you wouldn’t treat it. The psychological, that hopefully is going to be teased out with your conversation. I wouldn’t try to treat psychological, obviously, with PRP. But let’s get to some of these pictures, though, because I think a lot of our providers don’t really know what to look for. I know that you’ve seen quite a few people who are being followed by a gynecologist-

Charles Runels: Some of these women, saw gynecologists who never diagnosed the pathology the gyn just went for the pap smear and never stopped to look at what was going on.

You just mentioned … This, by the way, is his algorithm for pain. I don’t show this, obviously, expecting anybody to memorize this whole thing from my overview here, but I just want people to realize there’s some thought that goes into figuring out pain. They’re not just willy-nilly treating someone without making sure that someone, if they’re not a gynecologist or a dermatologist, that someone hasn’t thought through a differential diagnosis … If there’s a rash for example, it should be biopsied. Someone should be thinking about that.

This first one is a big one. There is a pain disorder that’s associated with low testosterone. This is stressed over and over when I talk to people who treat a lot of vaginal and vulvar pain. The vagina and the vulva needs testosterone to stay healthy, and there’s a actual syndrome associated with pain and birth control pills, which almost always drops testosterone levels. Some women are susceptible to that, and some are not, but that’s something to think about.

This vestibulodynia of different ideologies is a whole subject in itself, but interestingly, I did meet a woman at this last ISSWSH meeting who had a woman with long standing vestibulodynia that was of this [neuroproliperative 00:09:01] type that responded to our PRP. Somehow it decreased that inflammatory whatever makes things go on here. This is a whole area for research that we need to take up, talk about. But obviously this is not a healthy looking vestibule. When you have this erythema around Hart’s line, then it’s worth thinking about testosterone creams. I think it’s worth trying our PRP as a way to modulate that.

Again, I’m just skimming through this just so you can see this should be thought about. This is that Hart’s line that you just heard Dr. Posey talk about that one. That’s inflamed, and this responded to using testosterone and estrogen creams.

Our O-Shot® is not the cure all, end all, be all, but I think it’s an extra tool that can be used in the thoughtful treatment of these problems, so I just-

I just wanted people to get a look at what some of this neuroproliferative. Vestibulodynia is a horrible problem. Basically, someone stays inflamed to the point that then if the inflammatory agent is removed they still stay inflamed.

A lot of times, they’re treated with creams that have some sort of propylene glycol or paraben in it that causes the inflammation. You’ve got inflammation, you treat it with a cream that actually causes a chronic inflammation to the point that when it stops, sometimes they’re left with a continued process that turns into this.

I think that was the main thing. The other thing to think about is here’s the pelvic floor muscles. Normally, these have been treated historically by palpating, as you heard Dr. Posey talk about, palpating and finding the place where a person’s tender, just like you would look for trigger points in a tender back and in the same way that physiatrists are now injecting PRP to treat this.

When you find that tenderness, you can now inject PRP. That will usually hurt worse for about a week and then it goes away. You have anything to add to these pelvic floor injections?

Kathleen: Not really. I’ve never really done them. I refer to pelvic floor PT, but I will say that even of the lichen sclerosus patients I’ve seen, a lot of them have pelvic floor dysfunction. You just touch them and their levator ani muscle just almost goes into spasm. It’s interesting, a lot of women when they’re touched, they wanna squeeze that butt together and I’m telling them, “Look, put your butt down into the table.” There’s a lot of comorbidity there with vulvar pain and then these muscles getting involved is what I see.

Charles Runels: Just to add to that, we do have people in our group who work with the pelvic floor therapists. I know you have them in New Orleans. Our little town doesn’t have one. But that’s a good referral source. One of our people actually had a pelvic floor therapist put a satellite office in their office actually they had a good working relationship [inaudible 00:12:30]. His O-Shot helps her therapy work better. That’s worth looking into.

The way that he established that relationship is he just had her bring one of her patients over and he treated the patient with the therapist in the room so she could see what was involved. Then she went back and did this therapy as she normally would and had a nice result. It’s a way both to help their therapies work better and to help everybody’s business. Let’s see.

Kathleen: At the conference in Boston, they talked about putting Valium in the vagina.

Charles Runels: They did.

Kathleen: Did they talk about that at all?

Charles Runels: They did. It didn’t seem to be as helpful, at least the feeling I got from the lectures, as using Botox. That was something that was talked about.

We don’t have the research showing that our PRP works with pelvic floor trigger points, but it should apply, since that research has been done in the physiatry literature with back pain.

They did talk at ISSWAH about trigger point injections of Botox and they mention diazepam and suppositories, but Botox seemed to be the first choice on the menu (before diazepam).

100 units is what they talked about using, which would be one bottle of cosmetic Botox. Some are doing it under anesthesia. I know Andrew Goldstein was saying he likes to use it without general anesthesia so he can tell better about where to put it.

Let’s see. I think that was the main thing I wanted people to see was just that. Oh, yeah. He does a vulvar vestibulectomy but he says he does a whole lot less of these than he did in the beginning of his career when people were not using testosterone creams.

It was really talked about a lot, especially in someone who’s on birth control and how common it is that that gets dropped in people who develop these pain syndromes, not just this vestibulitis pain syndrome. But this is a last resort, obviously, but it’s something that’s done just to know what’s out there. It can be done if somebody develops this pain that just won’t go away.

I think that we’ll find that there’ll at least be a subset of these people that get better with our O-Shot. We’ll see. I think that was the main thing I wanted to show. I don’t feel like it’s my place to just put all this stuff out since it’s their intellectual property, but I just wanted people to see that there’s a lot of stuff out there and it’s worth, I think, attending one of their meetings. It’s called ISSWSH, International Society for the Study of Women’s Sexual Health. Maybe go there once every couple of years and get a good update.

Amnion with the Priapus Shot® Procedure

Okay. We didn’t have as many questions this week as we normally do. We had one question that showed up on the Priapus shot website about has anyone used PRP combined with amnion with the Priapus shot. Some of us have, but I don’t think I have enough experience yet to tell you that it’s working better. I think it would be worth trying if someone didn’t respond and you were treated Peyronie’s disease especially if you’re trying to heal scar tissue, or someone just wanted to get the best that you knew to do.

Again, amnion is not stem cells, it’s where you’re harvesting the proteins from the amniotic membrane and then they gamma-radiate it. There’s nothing living in there. You just have the cellular proteins, the amino acid peptide chains that code for wound healing. That research has been done. I think just as a general help, I always like to add in a couple things that have to do with marketing and something to do with business.

Press. Men’s Health

We got a really big hit that’s worth talking about when it comes to the Priapus Shot® procedure. If any of you guys are doing this, it’s worth talking about. Dr. Gaines is in our group and he popularized the Gains Wave™, which is combining the Priapus Shot® with shockwave therapy.

You can see the guy in the Men’s Health article talks about the Priapus Shot® itself, or the P-Shot®, and it’s a very complimentary article, somewhat sensational, but he’s an entertainer. This is “Men’s Health,” this is not “The New England Journal.”

Obviously, we don’t make claims we can’t fulfill and you want to have a consent form and make sure that your explanation is not the same as “Men’s Health” magazine, but Lord knows we get huge amounts of negative press that’s absolutely uninformed and factually wrong. Someone wants to make this a little bit entertaining by talking about his penis he claims was 10 inches when he put it in the pump, I don’t know, maybe it was 10 inches. Who knows? But I’m not one to dispute him.

It’s a nice article that at least can start the conversation and maybe lead to you helping some people who need your help for their erectile dysfunction. That article’s there if you just Google “Priapus shot in Men’s Health.” Some of us are combining the shockwave therapy when people want it. Just so you know, if you look on our director, PriapusShot.com/members/directory, I added a logo so that if you’re using shockwave therapy people can find you.

Our Directory and Helping People Find You

If you are doing shockwave therapy and want the logo by your name, let me know and I’ll add it.

If you go to the O-Shot® directory, we have a logo now if you’re doing radio frequency. I think what’s gonna happen is as the research becomes more available, as we do more research, then people are going to want different flavors of our procedure based on their problem. I know there are some things that one of these machines, like Dr. Posey just mentioned, someone who had dyspareunia had a small, constricted introitus, that’s not the place to use your radio frequency device.

But you can see I added this. This is what I added, Kathleen, to indicate you’re doing radio frequency. If you want one of those by your name, just send it to support. I’m gonna put it in here…

I just put it in the chat box. You just send that and let us know and we’ll put the little thing. This means you’re treating lichen, this means you’ve put five people in our research project or a survey, this means that you’re using radio frequency device, and we have one for laser’s too. I need to update.

This is the legend so that whomever’s using this directory knows what these little symbols mean. I just added this last week, so I need to add that to the legend so that people know that means you have Thermi-O or radio frequency device.

So, let’s see Dr. Desmond Ebanks just put something in the chat box. So, the automatic pump he uses, I don’t, the guy talks about this pump like it’s the bomb. Who knows if that’s part of his journalistic license, but he talks about this pump as being a pretty intelligent thing, so I’ll ask Dr. Gains what brand of pump they’re using.

Let’s see whats the other question…
which shockwave device do you recommend? As far as the shockwave device, what I have right now is the E-Vive. There are others out there, I think they’re all made by, or most of the main brands are made by the same company. They’re kinda re-branded, depending on who’s selling it. So I think a lot of it comes down to who you want to work with. And who’s having a good deal, and good support. But right now, I have the E-Vive, which is the one Eclipse sells, in my office.

Treating Acne

Let’s see, Dana Kirk just said here, okay, so here’s the question from Dana. She says, “Often the Vampire Facial®’s being administered for acne scarring often have some leftovers. Anyone injecting into the larger pock marks? If so, is it worth activating?”

Ok, so this is a good question about acne. When I treat acne, I use micro-needling. But two tips on that….

First of all, if it’s in their budget to do Juvederm. If you think about what happens to the divet, or say the divets in say a basketball, if you put more air in it? The divets become more shallow, just from expanding the ball. So even before you treat the pocks marks, or treat the acne scars, if you’ll use some Juvederm, if they can tolerate it, as in, do they have any room for some improvement in the cheeks, and if it’s a female, almost always they do, unless they’re obese, they’ll have some. You can add to their cheeks and things look better. And the acne scars are already smaller (before you actually treat them). At least the ones in the cheek area.

Then, micro-needle with PRP (Vampire Facial®), but also go intra-dermal and sub-dermal with your PRP, subsize/undermine the scar, just like you would if you were treating acne scars before we had the Vampire Facial®, so taking the bevel of your needle and sub-sizing the scar releases it some. I

Inject a little PRP sub-dermally, inject some intra-dermally, and then micro-needle on top of it. Intra-dermally as in blanching the skin.

And all those combined will get a really nice result. Usually I treat them every six weeks for three treatments, and they love it.

As far as activating it for the face, I usually don’t (I used to do so). Because I don’t think it adds to it enough to warrant the extra pain. In the face. But I do activate the PRP in the O-Shot®, the P-Shot®, and for loss of sensation in the breast.

The Order to Do Shock Wave, Radiofrequency, & O-Shot® or P-Shot®

So Sherry, I don’t see your question, it just says … maybe you can type it again. Okay, wait, here it is… “Does it matter which order you do the p shot, the shockwave therapy, and did the p shot … okay….”

So, the way I think about the energy, whether it’s shockwave, laser, or radio frequency, the way I’m thinking about it is, if you’ve ever used, say, insulin or growth hormone, if you just take, if you buy Omnitrope or a growth hormone, or Genitropin, whatever brand. These are small amino acid or peptide chains. It will tell you not to shake, to gently stir when you put the water in. Just shaking the vial, it mechanically shears the amino acid protein chains, so it’s like taking the words of the sentence and just chopping them up and turning them into letters. And now that amino acid chain no longer acts as a small peptide signal. Right? So these amino acid chains act as signals that plug in to receptors on the cell, and that’s how growth hormone, that’s how insulin, it’s how all those amino acid chains work.

Over 200 made by the pituitary gland that we know about. Peptide chain signals. So, imagine if you did that, I have no research to back this up, but imagine if you injected a peptide chain, and then now you hit it with shockwaves. In the same way, imagine what happens to an egg when you put it in a skillet and fry it. Obviously those peptides or those proteins are being changed.

So the bottom line is, I like to use the energy, whether it’s shockwaves, lasers, radio frequency, whatever it is. Use that on the tissue first. And then immediately afterwards, same visit, then apply your PRP. Now if you want to, if you did the shockwave yesterday, or last week, or three weeks ago, or a month ago, and you wanted to do PRP after that, that’s fine, you’re not hurting anything. And if you want to, if you did the PRP three weeks ago and now you want to add the energy, you can. But in my opinion, as soon as you add the energy, you are probably shutting down whatever growth was taking place, from the PRP that you put. So it’s like you’re stopping, it’d be like you just watered a seed, the stem cells are [inaudible 00:25:26] stem cells that you just put there. And now if you’re trying to generate more growth by damaging tissue, now you’re crushing the little sprout or whatever tissue is growing. You’re crushing it or injuring it, in my opinion, if you didn’t do the shockwave therapy before it has a chance to mature.

So I would try to do them back-to-back on the same visit. And not do anything else mechanical to disturb the growth of the pluripotent stem cells until at least six weeks out, maybe even eight. To give what you did a chance to work.

So if you did the P-Shot® three weeks ago, yeah, you could do the shockwave now, but you’d probably be stopping whatever further benefit might have occurred from that original P-Shot®. It might be better to give it at least another three weeks before you did the shockwave therapy.

How Your Losing the Chance to Take Care of at Least 30% of the People who Visit Your Website…

Okay. Let me give you guys, I don’t see any other questions that are up. I want to give you guys one quick marketing tip, and then unless somebody has another question, we’ll shut it down.

This one has to do with when people get to your website. It is something you can ask your web designer for. This is my old internal medicine website. And this is just a form and here’s the scenario that will happen. And this is why this form is so important. You don’t have to make it, I just want you to know it exists, and this is a ten minute job for your marketing person. And if you don’t have one of these, you’re losing about at least 30 to 40% of the traffic that you could be getting to call your office.

So let’s say that you’re in, let’s say that you’re, you do an o shot, or you do a vampire, or you just do a pap smear on someone. And they go back home, and they go to Thanksgiving dinner. And they tell their mother, sister, friend, cousin, whatever, how wonderful you are. And they say, oh, what’s their name. And they say, oh, it’s Dr. Posey.

So now they take out their cell phone, or they remember the name and tomorrow, day after Thanksgiving, they google you. And they wind up on your website. If all you have is stuff for them to read, they read it and they go away. And there’s very good chance that a week from now, they’re not thinking about you. It’s all done. They will never become your patient.

If you put something on here that they can have for free, that costs you nothing, not a free consult, it’s gotta be something that costs you nothing. If you put something on here that they can have for free, and we’ve all done this before, that’s worth something to them, but costs you nothing, somewhere between ten and 30 percent of the people who land there will do that.

And then, now you have their email address. They start getting your newsletter, and a certain percentage of those will eventually become your patients. So it gives you a chance- this is not the main way you get your patients. Most of your patients are gonna be word of mouth, or someone googling you. But this plugs the hole, and it will increase the number of people you have by about 20 to 30 percent, that come in through your website, by capturing those people who would have never called you, had you not created this form.

And the way you ask for it, is you decide something you’re going to give away, first of all. It could be, and I, it should be a podcast or an email, or downloadable book. It doesn’t even have to be your podcast. What I’m giving away here is a podcast where I’ve just recorded for an hour the benefits of walking. So it says, number one weight loss melt secret, free immediate download. So that takes them, you ask them for the first name and email address, and when they give you that, now they’re on your email list, every time you send out an email, they get it. And as soon as they do that, and you can sign up for this so you can see how it works, as soon as they enter that data, they’re taken to the place to download that.

So, it could be an email, excuse me, it could be a podcast or a video that you made. I know Dr. Posey made one on incontinence. So it could be free video on the treatment of incontinence. In exchange for first name and email. And so you tell your, here’s what you say to your web person, if you want to do this, you should write this down. And this works for Constant Contact, A-webber, Ontraport (what I use most), Mail Chimp, all those different places.

All those different places, it all works the same. And you can go online and figure how to do this yourself, but it’s a 30-minute job at most for whoever does your websites for you. You say you want a form and you want it to be in the right upper-hand corner of your website. On the homepage at least, maybe on all your pages, but at least on your homepage. And it should offer the thing that you’re giving away. And it should only ask for their first name and their email address, that’s it. If you ask for last name, you’ll lose about half of them. So first name and email address.

And then you let them know that you’re putting out a new health lessons every two weeks. Don’t call your newsletter a newsletter. Nobody really cares about your news. Give them a name that implies some sort of benefit. So I call this Health Lessons. You can call yours whatever. And then tell your person to put that on the form.

If you supply them the link to the thing you want to give away … You realize also on Amazon, there’s a lot of books for free. You could literally find a book that you can read on Kindle for free and give that away. But I recommend you find something either audible of a podcast or a video. Preferably something that you did. And that’s it. That one thing is gonna increase the production of new patients by your website by 20 to 30 percent. Now we talk more about this sort of thing in my workshop where I teach marketing, but there’s your freebie right there that is just some of the best stuff.

Okay. Let’s see if there’s any other questions and then we’ll shut this down. We didn’t have a lot of questions on the websites. Okay. I think that’s it. You want to add anything? And thank you for helping us, Dr. Posey. I know you’ve had a lot of … I think more experience with treating lichen with PRP than anybody.

Do you still treat the clitoris even if the woman is there for urinary incontinence?

By the way, the way I think about this, it’s all the freaking O-Shot, it’s just we’re varying the way we do it. Just like you do a hysterectomy and you vary the method based on who you’re taking care of. It’s all the same thing. But Dr. Posey made a good point and this is worth remembering, because some people asked me if they’re there for incontinence, do you still treat the clitoris? Or if they’re there for sex, do you still treat the anterior vaginal wall? Or if they’re there for lichen, do you still do the rest of the O-Shot? Or for pain, do you still do the rest of the O-Shot?

There’s two reasons why you treat all of it. One is people lie about sex. Everybody does. And so if someone says they’re there for incontinence, maybe they’re not. Maybe they’re just too embarrassed to tell you. Or maybe they’re living alone, single and they don’t want to tell you they have a lover. Whatever reason. Maybe they just decided it’s not your business. And of course, you would want to treat the clitoris if you’re treating for sex, but you would also want to treat it for incontinence because if you look at the anatomy, the clitoral tissue actually comes around and forms some of the structure for urinary incontinence.

Also, it could be that those nerves of micturition that come down through that area are helped and our clitoris is acting like the wick to help rejuvenate those nerves of micturition. We do know that we have people with urgent incontinence that are getting better as well. And we’re not sure exactly why.

So I always treat the clitoris even if it’s for incontinence. And of course, if you read Grafenberg, the urethra is very erotic in women and you would definitely want to treat (even if there for sex). Also, you have the female prostate gland or the Skene’s glands, so you would definitely want to treat the anterior vaginal wall, not just the clitoris if you were treating for sex because the urethra is such a sexual organ as well.

And if you’re treating lichen and you’re hopeful that it’s going to get better, and you’re down there anyway, why wouldn’t you go ahead and treat the structures that have to do with sex so that that can be recovering at the same time you’re treating the lichen itself?

One big plug though, if they have sclerosis or phimosis, where you cannot pull that clitoral hood back, which many of them do, then you can go ahead and treat them, but make sure that you don’t stop there and you refer them to Dr. Posey or someone else in our group who knows how … If you don’t know how, someone else who knows how to free up that clitoral phimosis. So if you can’t retract the clitoral hood all the way back to see the shaft, if all you can see is the tip of the glans or if you can’t even see the glans, then they need a surgical consult from one of the people in our group so that that can be exposed and be more responsive. It’s hard to have good sex if you can’t get to the clitoris.

Okay. I think that’s enough rambling. Anybody else have any questions? If not, I’m gonna shut it down. Thank you for your help, Dr. Posey. Thank you guys for being here. I’ll put a recording up by the end of the day.

What can you measure with a ruler that gives a clue about a woman’s ability to have an orgasm?

Kathleen: I just wanna say something that I hear … I mean it’s going off on a little bit of a tangent. But to me, a lot of times, they want the O-Shot because they want that penis and vagina orgasm. And yes, it does help that somewhat, but I’m really … I look at a lot of vaginas, and I’m really paying attention to that distance between the clit and the vagina and/or urethra. And it really … You oughta start looking at it, Charles, because it varies with women. Some of them, it is like five to seven inches.

Charles: Yeah, it’s huge.

Kathleen: When I talk to those people, they have never had a penis and vagina orgasm. It might be something to really examine the person before. And if you really talk to them about why they really want the O-Shot, I’m seeing 70 percent of them really want that penis and vagina. And it’s being advertised or said it’s gonna make them have that. Just be careful because if that distance is a long way, yeah, the orgasm will get better. But to bring you to surgery, in my opinion.

Charles: Let me add to that. First of all, what you said is backed up by research. And that research I think is actually on our O-Shot website. But there was MRI studies showing that the further the clitoris is from the vagina, the harder … It was a correlation between … It was done about two years ago. You know this research, so you’re seeing it actually in your patients.

Now, and I’ll also say that of the things that we treat, trying to help a woman achieve penis and vagina orgasm, who is able to have it with a vibrator, is one of our more difficult problems. I think our success is probably in the 30 to 40 percent range in that group. Where if you’re treating incontinence in a younger woman, stress incontinence is probably closer to 80 to 90 percent.

So I agree that something ... And it brings up another point in that I recommend, especially in the beginning, that people stick to the problems that we have the high success rate, so the provider doesn't become discouraged. I know you were very motivated and trusting it. But way back, years ago, when we didn't have so many people doing this and we had less research to back it up. But anybody, even with our current researcher who is just starting out, they should probably avoid treating, I think, until they have some success under their belt, the people who never had an orgasm because those are the people who are more difficult and probably they're always gonna need testosterone on top of what we're doing, I think.And the people who we just mentioned trying to have an orgasm with penis and vagina sex, they're more difficult. Stick to the stress incontinence, the dyspareunia, the lichen sclerosis, the women who can have an orgasm and wants to be stronger, those are our more easier cases. And in all cases, always, always, always, in my opinion, if they don't get well by the end of 12 weeks, then either offer them another treatment or give them their money back because we can make a profit and take good care of people without having to have people feel like we ripped them off.

Anything else, Kathleen?

Kathleen: I didn’t mean to say it wouldn’t help because I do think it helps and I do think you can even … I think the O-Shot, by putting it in the vagina, does shorten the distance a little bit. And maybe millimeters like what the P-Shot is doing. And it can get better, it just can’t … When you really see a big long distance, I would ask them and then I would just say, “Your orgasm is probably gonna get stronger, easier to obtain, but it may not help that.” I don’t know, it’s hard to give them a negative … I wouldn’t give them a negative embedded command. Just watch it if they’re there for penis and vagina orgasm.

Charles: I’ll tell you what I tell everybody. It’s good advice. And what I tell everyone when I’m leaving the room is I’ll say, “You just spent whatever amount of money it is. And for that much money, you have to love it. And if you don’t love it, I want to know about it.” Because of course, I’m gonna be following up with them. But what I found when I follow up with some of the people … So when people contact me and they tell me they’re not happy, I refer them to the doctor who took care of them because I’m not their doctor. So I don’t need to be involved. But it’s helpful for me to know who took care of them. Then I call the doctor and talk to them and see if I can offer help.

But back to this thing about satisfaction and setting expectations. I think that what I’ve seen happen sometimes when people are not happy is they never let their doctor know. Because maybe they’re afraid they’re gonna hurt their feelings or there’s gonna be some sort of conflict or something. I think it’s helpful to actually tell your patient, “I want to know. I want to know if you don’t love it because I want to take care of you, and I don’t want you to feel like that our energy and time and your money has been wasted.” And that really helps a lot, both with you getting them well and helps prevent them sliding away disgruntled without you ever knowing about it.

And in the process, you can say what you just mentioned, Kathleen, that if it’s a more difficult case, it’s worth telling them, “This is something that a percentage of,” if you’re dealing with someone who’s trying to have an orgasm with penis and vagina sex, “This is something that doesn’t work as well. We have a much higher percentage with treating stress incontinence, but we do have successes that by our surveys, are in the 30 to 40 percent range. If you want to try it, we’ll do it. But I want you to love it. And if you don’t, let me know. And we’ll either repeat it or we’ll figure out something else, including, I won’t keep your money.”

And in the end, although you give back money occasionally, you wind up making many more people happy and making more money and you sleep better at night.

Okay, I think that’s it. Thank you guys for your attention ’cause this thing … What we’re doing here, I think, is really changing medicine and I’m the facilitator between all you guys thinking about it and all the feedback and all the good research. So keep it coming and I’ll try to keep pouring our money back into it.

We have two double-blind placebo studies going on now. We’re having a little trouble filling the orgasm study (click to help), so I’m gonna put out a link to that again. So if you guys know people who live in the Washington D.C. area … Bottom line though is we’re investing into the research. We’re investing into supporting our group. And I think you’re gonna see medicine change a lot in the next five years from what we’re doing. Okay, you guys have a good day. Thank you, Dr. Posey.